| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
2,811 |
2,699 |
$28K |
| D0120 |
Periodic oral evaluation - established patient |
2,861 |
2,727 |
$19K |
| D1206 |
Topical application of fluoride varnish |
2,821 |
2,705 |
$14K |
| D0272 |
Bitewings - two radiographic images |
936 |
890 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
780 |
698 |
$2K |
| D1110 |
Prophylaxis - adult |
254 |
245 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
234 |
231 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,005 |
270 |
$2K |
| D1351 |
Sealant - per tooth |
285 |
84 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
45 |
25 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
167 |
164 |
$852.98 |
| D0240 |
|
157 |
99 |
$372.06 |
| D0210 |
Intraoral - complete series of radiographic images |
24 |
24 |
$303.00 |
| D0140 |
Limited oral evaluation - problem focused |
25 |
24 |
$296.20 |
| D0274 |
Bitewings - four radiographic images |
57 |
57 |
$293.06 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
77 |
68 |
$277.24 |
| D0330 |
Panoramic radiographic image |
48 |
48 |
$160.16 |
| D0350 |
|
289 |
33 |
$54.18 |
| D1330 |
|
3,156 |
2,982 |
$0.00 |
| D1310 |
|
3,157 |
2,983 |
$0.00 |